The Future of Payer-sponsored Electronic Health Records

Health Industry Insights' Lynne Dunbrack examines the current state of electronic health record technologies used by US payers and presents key findings of two surveys regarding payer deployment of and data contribution to various forms of EHRs.

“The slow progress in payer-sponsored EHR initiatives is reflective of the highly fragmented US healthcare industry”
-Lynne Dunbrack of Health Industry Insights

Undeniably, payers have more electronic health data than any other healthcare stakeholder, and so are uniquely poised to play an important role in contributing data to their own and other stakeholder electronic health records (EHRs).

It should be noted that in this context, the term EHR is being used in its broadest sense to encompass various forms of health records. Payer-based health records (PBHRs) consist of data sourced by payer core administrative systems, including medical and pharmacy claims systems. Electronic medical records (EMRs) and electronic health records consist of data sourced predominantly by provider healthcare information systems. These two terms, while often used interchangeably by the industry, are viewed as separate but related technologies by Health Industry Insights. Consumer-controlled personal health records (PHRs) can consist of data from payers and/or providers, as well as data from the consumer.

Acquiring vendors

To date, the predominant form of payer contribution to EHRs has been to offer members a PHR. In addition to simply offering a PHR on a private-label basis, there have been several notable examples of payers making considerable investments in EHR technology, including investing in or acquiring vendors that offer this capability.

For example, Aetna acquired ActiveHealth Management for approximately $400 million in May 2005 and operates it as a branded, standalone business. ActiveHealth Management offers ActivePHR along with other health management and data analytic solutions.

Blue Cross Blue Shield of Tennessee (BCBSTN) formed Shared Health as a wholly owned subsidiary in July 2005. The Shared Health Clinical Health Record (CHR) is a PBHR with data sourced from BCBSTN and TennCare, Tennessee’s Medicaid program. MySharedHealth is the consumer view into CHR.

Availity LLC is a unique joint partnership between Blue Cross and Blue Shield of Florida Inc. (BCBSF), Humana Inc., and Health Care Service Corporation (HCSC). In May 2007, leveraging the connections established for administrative transactions, Availity launched Care Profile, a multipayer PBHR, accessible through its portal.

HCSC acquired MEDecision earlier this year; the transaction was valued at approximately $121 million. MEDecision’s Nexalign suite includes Care Summaries, a PBHR that aggregates and presents clinically validated payer-sourced data. Much of this activity happened two or three years ago, after the Bush administration pronounced in 2004 that every American would have an electronic health record by 2014. So where are payers today in their investment plans for PBHRs, PHRs, and other forms of EHRs?

Collaborative initiatives

In two separate surveys about payer IT investment priorities, Health Industry Insights asked US payers about the current status of deploying PBHRs and PHRs, investing in EMRs, and contributing payer data to provider-owned EHRs.

When asked which collaborative initiatives do you expect your organization to invest in, in 2008, both provider EMRs and EHRs were mentioned by 38.7% of the respondents. Increasingly, payers are investing in applications to be used by their members and providers. This same survey revealed that the top three factors driving investment were response to consumerism, and provider and employer demands. Investments in external applications are thus creating a new tension between internal and external application investment allocation as well as new integration and data requirements.

PBHRs are not widely deployed by payers, nor will they be any time soon according to a 2008 Health Industry Insights survey. About 10% of the surveyed payers have a PBHR in production, while 14.3% and 9.5% of respondents indicated that they are evaluating solutions or piloting solutions, respectively. Less than five percent reported planning for a PBHR in 2009, not one organization reported planning for a PBHR in 2010, and 57.1% reported no plans at all.

Certainly, PBHRs have their merits; they aggregate member health information such as recent diagnoses, procedures, and hospital admissions; medication history; and lab tests (ideally along with results), thereby creating a consolidated view for providers without access to a provider-owned EHR that is fed with data from clinical information systems.

However, workflow and data availability issues have inhibited widespread provider adoption of PBHRs, especially if the payer is not one of the dominant players in the geographic market. In turn, lackluster adoption of these PBHRs have discouraged other payers from offering their own solutions.

In the 2008 Health Industry Insights survey, payers were asked the status of contributing data to various EHR initiatives. Payers were more likely to be actively contributing data to a community-based health record hosted by a third party than any other types of EHR; 26.6% of respondents indicated that their organization is contributing data (e.g. in production) and another 19% are evaluating solutions. Other frequently mentioned initiatives included provider-owned EHRs (19% in production and 26.6% evaluating solutions).

Future outlook

Much of the investment activity in PBHRs happened two to three years ago, after the Bush administration pronounced that every American would have an electronic health record. Today, while the major national payers offer a PHR to their members, just a few offer a PBHR to their providers and only in certain geographic markets. For example, Availity Care Profile is only available in Florida and Texas, and HCSC operates the Blue Cross Blue Shield plans of Illinois, New Mexico, Oklahoma, and Texas. Achieving a critical mass of members and providers in any given geographic market remains a major inhibitor to widespread use of PBHRs.

Providers, which typically contract with multiple payers, want multipayer solutions to ease workflow issues and increase the likelihood of finding health information for a given patient. With few exceptions, most payers have been unwilling to collaborate with their competitors on such payer data sharing initiatives, preferring to go it alone to preserve branding and competitive advantage in the marketplace. The lack of widespread Medicaid and Medicare data also creates a data void.

The slow progress in payer-sponsored EHR initiatives is reflective of the highly fragmented US healthcare industry. Members change health plans every few years, creating a financial disincentive for payers to invest in strategies that have long term rather than immediate benefits. Providers contract with multiple payers, and any one payer, especially the national payers, might not represent a significant percentage of a provider’s revenue stream to justify the provider changing administrative or clinical workflows or adopting new technology for the sake of a few members of that health plan.

The year 2014 is six years away. Unless there are fundamental changes in the US healthcare system that create a more stable relationship between payer and member, as well as between member/patient and provider, then payer-sponsored EHRs will continue to be experimental only with a few health plans rolling them out in select geographic markets where critical mass can be achieved. Without critical mass measured in terms of the number of patients with data readily available in the EHR, providers will continue to be reticent to adopt EHRs sponsored by individual payers.

Lynne Dunbrack is a nationally recognized thought leader in the application of information technology (IT) to the business problems of the health industry. Her understanding of industry needs is grounded in experience over the last 25 years working as a consultant and in the healthcare field.

As Program Director for Health Industry Insights, Dunbrack provides research-based advisory and consulting services that enable health provider and payer executives to maximize the business value of their technology investments and minimize technology risk through accurate planning.

Visit Health Industry Insights at www.healthindustry-insights.com or contact the company at info@healthindustry-insights.com.